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Transcript
COCA Call Information
For the best quality audio, we encourage you to use your computer’s audio.
Webinar Link:
https://zoom.us/j/887744874
If you cannot join through digital audio, you may join by phone in listen-only mode:
US: 1(646) 876-9923 or 1(669) 900-6833
Webinar ID: 887 744 874
International numbers available: https://zoom.us/u/anixAVglV
All questions for the presenters must be submitted through the webinar system via the Q&A button. Please do not ask a question using the chat button.
2. Summarize frequent clinical, laboratory, radiographic, and pathologic findings and outcomes among cases; and
3. Discuss CDC recommendations for clinicians.
At the conclusion of the session, participants will be able to accomplish
the following:
Today’s Presenter
LCDR Tara Jatlaoui, MD, MPH (USPHS)
Medical Epidemiologist
Clinical Team Lead, 2019 CDC Lung Injury Emergency Response
Centers for Disease Control and Prevention
Centers for Disease Control and Prevention
7
Outbreak of Lung Injury Associated with E-cigarette Product Use or Vaping
Information for Clinicians
CDC 2019 Lung Injury Response
Updated as of September 17, 2019
8
Overview Background
E-cigarette or vaping products
Clinical FeaturesFrequent Clinical, Laboratory, Radiographic, and Pathologic Findings and Outcomes
CDC Recommendations for CliniciansHistory, Diagnosis, Clinical Management, Evaluation of Pathologic Specimens at CDC, Autopsy, What to Tell Patients, Case Reporting to Public Health Authorities, Additional Resources
Limitations and Knowledge Gaps
9
Background As of September 17, 2019, 530 cases of lung injury associated with the use
of e-cigarette products or vaping have been reported to CDC
– data updated weekly at CDC’s outbreak website
– 38 states, 1 U.S. territory; 7 deaths have been confirmed
No specific etiology has been identified, but all patients have reported using e-cigarette products, or vaping
– Most have reported using products containing THC
– Many have reported using THC and nicotine; some only nicotine
CDC issued recommendations for clinicians, public health officials, and the public through its health advisory network (HAN) on August 30, 2019
Initial clinical experience summarized in recent publications in Morbidity & Mortality Weekly Report (MMWR) and New England Journal of Medicine (NEJM)
All have reported use of e-cigarette products, or vaping, within 90 days of illness
– Most have reported using cannabinoids such as Δ-9-tetrahydrocannabinol (THC) or cannabidiol (CBD)
– Some have reported nicotine use alone
No single device type has been reported consistently (though device types have not yet been well-characterized)
No single e-cigarette product or substance (including cannabis products) has been reported consistently
11
CDC Confirmed Case Definition (September 18, 2019)
Using an e-cigarette ("vaping") or dabbing* in 90 days prior to symptom onset
AND
Pulmonary infiltrate, such as opacities, on plain film chest radiograph or ground-glass opacities on chest CT
AND
Absence of pulmonary infection on initial work-up. Minimum criteria are
– A negative respiratory viral panel and
– A negative influenza PCR or rapid test, if local epidemiology supports influenza testing; and
– All other clinically-indicated respiratory ID testing (e.g., urine Antigen for Streptococcus pneumoniaeand Legionella, sputum culture if productive cough, bronchoalveolar lavage (BAL) culture if done, blood culture, HIV-related opportunistic respiratory infections if appropriate) are negative
AND
No evidence in medical record of alternative plausible diagnoses (e.g., cardiac, rheumatologic, or
neoplastic process)
12
CDC Probable Case Definition (September 18, 2019)
Using an e-cigarette ("vaping") or dabbing* in 90 days prior to symptom onset
AND
Pulmonary infiltrate, such as opacities, on plain film chest radiograph or ground-glass opacities on chest CT
AND
Infection identified via culture or PCR, but clinical team** believes this infection is not the sole cause of the underlying lung injury OR Minimum criteria to rule out pulmonary infection not met (testing not performed) and clinical team** believes this infection is not the sole cause of the underlying lung injury
AND
No evidence in medical record of alternative plausible diagnoses (e.g., cardiac,
rheumatologic, or neoplastic process)
**Clinical team caring for the patient.
13
Patient Exposures in the Lung Injury Outbreak
Series of 53 cases from Illinois and Wisconsin*
– All had history of e-cigarette use and related products
GI symptoms sometimes precede respiratory symptoms
– Tend to resolve quickly after admission
– Evaluation for GI-related illness unrevealing
Almost all published cases have been hospitalized
– Many with ≥1 antecedent evaluation in ambulatory settings
22
Frequent Presenting Signs upon Hospital Admission
Fever
Tachycardia
Tachypnea
Hypoxemia (even in patients without respiratory symptoms upon presentation)
– One of 53 patients in the recently published 53-case series in New England Journal of Medicine* did not report respiratory symptoms, but had oxygen saturation of 91% on room air on admission
* Layden J, et al. Pulmonary illness related to e-cigarette use in Illinois and Wisconsin—preliminary report. NEJM 2019
– Elevated serum markers of inflammation (e.g., ESR, CRP)
– Transient, mild elevation in serum transaminases
Chest imaging
– Abnormal findings may or may not be present on initial imaging, but develop eventually
– Bilateral opacities on plain radiograph or ground-glass opacities on chest computed tomography (CT), often with sub-pleural sparing
Imaging of abdomen/pelvis usually unremarkable except for bilateral opacities in cuts of lower lung fields included on CT
24
Clinical Course
Initial therapies focused on presumed infectious etiologies
– Empiric antibiotics with or without steroids
– Observation with supportive therapy other than antibiotics or steroids
Many patients have experienced sub-acute or acute hypoxemic respiratory failure requiring supplemental oxygenation and at times ventilatory support, including with intubation and mechanical ventilation or extracorporeal membrane oxygenation
Patients who did not respond to antibiotics alone have tended to respond to systemic corticosteroids (either alone or concurrent with antibiotics)
25
Frequently Performed Diagnostic Evaluations
Appropriate extensive evaluations for infectious etiologies often completed without an identified cause
Use of pulmonary function testing has been highly variable, mostly depending upon institutional practices
Some patients evaluated for lung injury with bronchoscopy with bronchoalveolar lavage or lung biopsy (either transbronchial or surgical via video-assisted thoracoscopic surgery [VATS] or thoracotomy)
– Additional patients considered for these procedures but were too ill
– Roles and frequencies of biopsy methods remain unknown
26
Evaluation of Pathologic Specimens
Both routine histopathologic and special evaluations of specimens have been performed
Routine processing of tissues includes the application of alcohol, which removes lipids
Therefore, as a special evaluation, lipid-staining (e.g., Oil Red O, Sudan Black) has been performed on fresh tissues and bronchoalveolar lavage fluid
27
Spectrum of Clinical and Pathologic Diagnoses
Acute lung injury and adult respiratory distress syndrome (ARDS)
Diffuse alveolar damage
Lipoid pneumonia
Acute necrotizing pneumonitis
Organizing pneumonia with lipid-laden macrophages
Non-specific inflammation
Hypersensitivity pneumonitis
Eosinophilic pneumonia
28
Outcomes
Specialists in pulmonary medicine, critical care, infectious diseases, pathology, or toxicology frequently involved in patients’ care
Despite illness severity, most patients have survived to hospital discharge
– Most patients have been young and healthy pre-illness
– Some patients who have not recovered to pre-illness pulmonary function at time of discharge, demonstrated improvement during post-hospitalization evaluation
– Other patients still had reduced pulmonary function during post-hospitalization evaluation
– 7 patients died in the hospital (as of September 17, 2019)
Recommendations for Clinicians
30
Recommendations for Clinicians: Overview
History
Diagnosis
Clinical Management
Evaluation of Pathologic Specimens at CDC
Autopsy
What to Tell Patients
Case Reporting to Public Health Authorities
CDC will provide updates as more information becomes available
31
Recommendations for Clinicians: History
Ask patients who report e-cigarette product use, or vaping, within the last 90 days about signs and symptoms of respiratory illness
Ask patients who present with signs and symptoms of respiratory illness about e-cigarette use, or vaping, within the last 90 days
If e-cigarette product use is suspected as a possible etiology of a patient’s respiratory illness, obtain a detailed history about e-cigarette product use, or vaping
32
Recommendations for Clinicians: History (Cont’d)—e-cigarette product use
Substances used: nicotine, cannabinoids (e.g., marijuana, THC, THC concentrates, CBD, CBD oil, synthetic cannabinoids [e.g., K2 or spice], hash oil, Dank vapes), flavors, or other substances
Substance sources: commercially refillable e-liquids (e.g., bottles, cartridges, or pods), commercial non-refillable e-liquids, homemade or street sources
33
Recommendations for Clinicians: History (Cont’d)—e-cigarette product use
Devices used: manufacturer; brand name; product name; model; serial number of the product, device, or e-liquid; if the device can be customized by the user; and any product modifications by the user (e.g., exposure of the atomizer or heating coil)
– Where the devices were purchased
– Method of use: aerosolization, dabbing, dripping, or re-use of old cartridges or pods with homemade or commercially bought e-liquids
– Sharing e-cigarette products (devices, liquids, refill pods, or cartridges) with others (to identify other cases)
34
Recommendations for Clinicians: Diagnosis
Consider all possible causes of illness (e.g., infectious, rheumatologic, neoplastic) in patients reporting respiratory with or without GI symptoms and e-cigarette product use
Consider consultation with specialists (pulmonary, infectious disease, critical care, medical toxicology, pathology) as clinically indicated
Lipoid pneumonia associated with inhalation of lipids in aerosols generated by e-cigarettes, or vaping, has been reported based on the detection of lipid-laden alveolar macrophages obtained by bronchoalveolar lavage and lipid staining (e.g., Oil Red O, Sudan Black)
– The decision about whether to perform bronchoalveolar lavage, with or without bronchoscopy, should be based on the overall clinical picture
35
Recommendations for Clinicians: Diagnosis (Cont’d)
Lung biopsies have been performed on some patients
– The decision about whether to perform biopsy (whether transbronchial or surgical) should be based on the overall clinical picture.
– If a lung biopsy is obtained, consider lipid-staining during pathologic examination.* Because routine tissue processing involves the application of alcohols, which remove lipids, lipid-staining is best performed on fresh tissue.
– Before the procedure consider consultation with pulmonary, critical care, pathology, or other specialties to inform any evaluation plan
– However, conducting routine tissue processing and histopathologic evaluation is still important.
* Additional information on lipid-staining is available at: https://www.cdc.gov/tobacco/basic_information/e-cigarettes/severe-lung-disease/healthcare-providers/index.html.
36
Recommendations for Clinicians: Diagnosis (Cont’d)
Contact public health officials as needed for technical assistance with laboratory testing, including for guidance regarding whether to retain specimens, storage instructions in the event of long-term storage, and collection of specimens for indications other than clinical care
If retaining of specimens is anticipated, contact your facility’s laboratory since routine practice might result in discarding of specimens before desired
37
Recommendations for Clinicians: Clinical Management
Decisions regarding outpatient versus inpatient management should be based on individual clinical circumstances
Evaluate and treat as appropriate for other possible causes of illness (e.g., infectious, rheumatologic, neoplastic)
Consider consultation with specialists (pulmonary, infectious disease, critical care, medical toxicology)
38
Recommendations for Clinicians: Clinical Management (Cont’d)
Clinical improvement of patients with lung injury associated with e-cigarette use, or vaping, has been reported with the use of corticosteroids
– Dosing, route of administration, duration, and timing have varied
– The decision to use corticosteroids should be made on a case-by-case basis based on risks and benefits and the likelihood of other etiologies
Patients who have received treatment for lung injury related to e-cigarette product use, or vaping, should undergo follow-up evaluation as clinically indicated to monitor pulmonary function
39
Recommendations for Clinicians: Evaluation of Pathologic Specimens at CDC*
If feasible, submission of formalin-fixed (wet) lung tissues is encouraged
CDC’s Infectious Disease Pathology Branch can perform lipid-staining on formalin-fixed (wet) lung tissues using osmium tetroxide before routine tissue processing and paraffin embedding
– However, lipid staining cannot be performed on formalin-fixed, paraffin-embedded lung tissue blocks, because they have undergone processing that removes lipids
CDC’s Infectious Disease Pathology Branch will also review tissue histopathology and perform additional testing, including testing for possible infectious etiologies
* Additional information on lipid-staining is available at: https://www.cdc.gov/tobacco/basic_information/e-cigarettes/severe-lung-disease/healthcare-providers/index.html.
40
Recommendations for Clinicians: Evaluation of Pathologic Specimens at CDC* (Cont’d)
Please first report any possible cases of lung injury associated with e-cigarette product use, or vaping, to your state, territorial, tribal, or local health department
Pre-approval is required prior to submission of any tissue specimens. For pre-approval, health departments should contact [email protected][email protected].
* Additional information on lipid-staining is available at: https://www.cdc.gov/tobacco/basic_information/e-cigarettes/severe-lung-disease/healthcare-providers/index.html.
In the event of a fatal outcome, autopsies can be considered
– Collection of fresh lung tissue for staining of lipids, formalin-fixed (wet) lung tissue, and submission of lung and other tissues for routine tissue processing, paraffin-embedding, and evaluation of histopathology should be considered
– Infectious disease testing, including postmortem microbiology and molecular testing, should also be considered if indicated by patient history or autopsy findings
Contact public health officials as needed for technical assistance with laboratory testing
42
Recommendations for Clinicians: What to Tell Patients Regardless of the ongoing investigation, e-cigarette products should not
be used by
– Youth and young adults
– Pregnant women
– Adults who do not currently use tobacco products
Regardless of the ongoing investigation, anyone who uses e-cigarette products should
– Not buy these products off the street (e.g., e-cigarette products with THC, other cannabinoids)
– Not modify e-cigarette products or add any substances to these products that are not intended by the manufacturer
– Monitor yourself for symptoms (e.g., abdominal pain, nausea, vomiting, diarrhea, cough, shortness of breath, chest pain)
– Promptly seek medical attention if you have concerns about your health
43
Recommendations for Clinicians: What to Tell Patients
For adults trying to quit tobacco product use, including e-cigarettes
– Use evidence-based treatments, including counseling from a healthcare provider and FDA-approved medications
During the current investigation of lung injury associated with e-cigarettes, or vaping, if you are concerned about these specific health risks
– Consider refraining from using e-cigarette or vaping products
– If you are an adult who uses e-cigarettes because you have quit cigarette smoking, do not return to smoking cigarettes
– If you continue to use e-cigarettes, carefully monitor yourself for symptoms and see a healthcare provider right away if you have symptoms like those reported in this outbreak
44
Recommendations for Clinicians: What to Tell Patients (Cont’d)
If you are concerned about harmful effects from e-cigarette products, call your local poison control center at: 1-800-222-1222
Submit detailed reports of any unexpected tobacco or e-cigarette-related health or product issues to the FDA via the online Safety Reporting Portal: https://www.safetyreporting.hhs.govexternal icon
Recommendations for Clinicians: Case Reporting to Public Health Authorities
Report cases of lung injury of unclear etiology and a history of e-cigarette product use, or vaping, within the past 90 days to your state or local health department
– Reporting of cases may help CDC and state health departments determine the cause or causes of these pulmonary illnesses
Determine if any remaining product, including devices and liquids, are available for testing
– Coordinate testing with the local or state health departments
46
Recommendations for Clinicians: Additional Resources
CDC will provide updates as more information becomes available
CDC website with updates for the ongoing investigation of lung injury associated with e-cigarette products use, or vaping: https://www.cdc.gov/tobacco/basic_information/e-cigarettes/severe-lung-disease.html
Information sources have included both confirmed and unconfirmed reports and small case series
– Anecdotal data can generate hypotheses but alone are insufficient; clinical information to support range of diagnoses has been lacking
– As of September 17, 2019, of 530 reported cases, <20% have been described in published literature; representativeness of published cases is unknown
Outbreak surveillance case definitions are intended for public health data collection purposes and not intended for use as a clinical diagnostic tool or replacement for individual clinical judgment
– No diagnostic criteria exist
49
Limitations and Knowledge Gaps (Cont’d)
Most cases have been severe illness resulting in hospitalization, but true spectrum of illnesses (including less severe illness) could be unrecognized
Investigations in affected states have been ongoing, but national efforts to coordinate, centralize, and standardize data collection efforts have been underway since August 16, 2019
No systematic data yet for exposure (including products, quantities, sources) or clinical information
50
Limitations and Knowledge Gaps (Cont’d)
Available data point away from a purely infectious etiology, but this does not exclude the possibility of concurrent processes
– No decision-making tools to distinguish infection versus non-infection at presentation, so important to rule out and empirically treat infectious etiologies as appropriate, even in patients with exposure history
– Patterns of illness could change with the approaching respiratory virus season
Remains unclear whether this is a new syndrome or a newly recognized one previously thought to be pneumonia or pneumonitis of unclear etiology
51
Limitations and Knowledge Gaps (Cont’d)
Although most patients have survived to hospital discharge, whether there are post-illness sequelae (e.g., reduced pulmonary function) after hospital discharge is not yet known for most patients
Age-related differences in illness have not been assessed
– Outbreak predominantly has affected younger, healthy patients, possibly reflecting different use patterns conferring increased risk compared with older patients
– Alternatively, diagnosis could be more complicated in adults who are more likely to have chronic lung disease or other medical comorbidities, leading to under-recognition of illness in adults
– Unclear whether adults have more severe illness more likely to result in death
52
Limitations and Knowledge Gaps (Cont’d)
Lipoid pneumonia has been reported in historical and recent case reports and series, but important caveats remain
– Clinical significance of lipid-laden macrophages remains undetermined—are these markers of disease or markers of exposure?
– Bronchoalveolar lavage has not been obtained universally on bronchoscope evaluation, and in turn nor has lipid-staining (a non-routine procedure), so frequency of finding is uncertain
– Characteristics of cellularity of bronchoalveolar lavage fluid are uncertain because they could be altered by antibiotics or steroids and influenced by timing of therapies and interventions
Autopsy has not been performed for all cases resulting in death, and results have not been reported for all cases when performed
53
Summary
CDC’s investigation has not yet identified any specific substance or e-cigarette product linked to all cases
– Most patients have reported using cannabinoids such as THC or CBD
– Some have reported nicotine use alone
Most patients have been hospitalized with respiratory illness and received treatment for presumed infectious etiologies; some have responded to steroids with or without antibiotics
Report possible cases to and coordinate product testing with your health department
CDC will provide updates as information becomes available
For more information, contact CDC1-800-CDC-INFO (232-4636)TTY: 1-888-232-6348 www.cdc.gov
The findings and conclusions in this report are those of the authors and do not necessarily represent the official position of the Centers for Disease Control and Prevention.
Additional Data from Wisconsin and IllinoisLayden J, et al. Pulmonary illness related to e-cigarette use in Illinois and Wisconsin—preliminary report. NEJM 2019
Dosing of Corticosteroids in Recent Outbreak Reports
Publication Dosages and medications
Davidson K, et al. Outbreak of e-cigarette-associated acute lipoid pneumonia—North Carolina, July–August 2019. MMWR 2019;68(36).
5/5 patients received intravenous methylprednisone(120 mg–500 mg daily); all discharged home on taper of oral prednisone (dose and duration not specified)
Maddock S, et al. Pulmonary lipid-laden macrophages and vaping. NEJM 2019.
2/6 patients received “high-dose glucocorticoids” (dose, duration, and discharge regimen not specified); 2 other patients received “short-course of prednisone” before hospitalization (dose and duration not specified)
Layden J, et al. Pulmonary illness related to e-cigarette use in Illinois and Wisconsin—preliminary report. NEJM 2019
“majority of patients have received prolonged courses” of systemic glucocorticoid therapy
Topic: 2019–2020 Recommendations for Influenza Prevention and Treatment in Children: An Update for Pediatric Providers
Date: Thursday, September 26, 2019
Time: 2:00-3:00 p.m. ET
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